A whole host of
things need to be said here, and I don’t have time for them all. Let me start by
saying that while the language of Medicare is that Canadians get "medically
necessary services" paid for by the state, this is not at all so. Among the
services that are not covered are pharmaceuticals (increasingly important as
many forms of surgery, etc. are now being supplanted by drugs regulating the
body’s functions), dentistry, home care, chiropractic (in most provinces), and a
number of other services. And there is a wide range of new diagnostic and other
services that it is not yet clear that Medicare will cover. Such as gene
therapy. In fact, one of the "brilliant" research papers for the Romanow
commission argued that in fact technology need not be a cost driver for the
health care system because it was only a cost driver if we actually used these
technologies….

Let’s talk about a
few other aspects of whether we get the care that we need in Canada.

Queuing

Queuing is a
controversial measurement, not least because there may be many explanations for
the queuing, many of them medically justifiable, so that aggregate queuing
figures may conflate those whose waiting poses no health or other risk with
those whose health may be impaired or may suffer pain while waiting.

That being said, in
a system in which health services are free at the point of consumption, queuing
is the most common form of rationing scarce medical resources. And since patient
satisfaction plays no part in determining incomes or other economic rewards for
health care providers and administrators in the public system, patients’ time is
treated as if it has no value. There are no penalties in the system for making
people wait.

It is thus not
surprising that the measures of queuing now available, including the Fraser
Institute’s annual report card Waiting your turn,[5] indicate a
lengthening of queues for a great many medical services, including access to
some specialists, diagnostic testing and surgery. What is surprising is that
those administering the system must rely on external studies, not having
implemented modern information systems to monitor waiting periods and to
identify those who have had excessive waits.

I’d also like to
point out that while we talk a lot about queuing in the Canadian health care
system, and we talk as if we know how many people are waiting and how long they
wait, in fact we do not know this at all. In fact, ironically for the largest
single program expenditure of governments in Canada, we know astonishingly
little about what we get for our money. As my colleague David Zitner, Director
of Medical Informatics at Dalhousie University in Halifax, and Health Policy
Fellow at my Institute, likes to say, no health care institution in Canada can
tell you how many people got better, how many people got worse, and how many
people’s conditions were left unchanged by their contact with their institution.
None of them can give you an answer. No one knows how many people died while
waiting for needed surgery. No one knows how many people are queuing for any
particular procedure, or how many people cannot find a family doctor. Mostly we
have guesswork, anecdotes and subjective measures, not objective ones (such as
the Fraser Institute reports mentioned earlier). We don’t even know how long
someone has to wait before they’ve waited "too long", because the health care
system does not establish official standards for timely care, although
presumably even Mr. Romanow would agree that someone who died while waiting for
care may have waited a tad too long.

All of this is due,
as I argued in a major paper I co-authored last year,[6] to the
conflict of interest at the heart of Medicare, in which the people who are the
ultimate providers of health care services in Canada are also the people charged
with regulating the system and with quality assurance. Since no one is a
competent judge of their own performance, and no one likes to be held
accountable for their work, the result is that the health care system simply
doesn’t set tough standards or collect the information that would allow us to
hold the system’s administrators accountable for their stewardship of our health
care and the billions of dollars they spend. The people who would collect the
information are also the people whose performance would be assessed if useful
information were made available. There appears to be no legal obligation for
governments actually to supply the services they have promised to the
population. This is an appalling double standard, as no responsible regulator
would permit a private supplier of insurance to behave in this way, as a recent
background paper for my Institute makes clear.[7]

Access to doctors
and medical technology

Aggregate numbers of
doctors per 1000 population do not give a good picture of access to physicians
in, say, cities versus rural areas within countries, nor of proportions between
scarce specialists and plentiful GPs, nor of the quality of medical training. On
the other hand, it does provide a crude measure of the overall state of access
to qualified practitioners. On this measure, Canada performs badly. In 1996 this
country had 2.1 practicing physicians per 1000 population, while of the
comparison group only two (Japan and the UK) had a lower ratio: Australia (2.5),
France (3.0), Germany (3.4), Japan (1.8), Sweden (3.1), Switzerland (3.2), UK
(1.7) and U.S. (2.6). Thus, even in countries with lower per-capita spending
than Canada, there is greater access to physician services.

With respect to
medical technology, Canada’s performance is also unimpressive. In a study[8]
comparing Canadians’ access to four specific medical technologies (computed
tomography or CT scanners, radiation equipment, lithotriptors and magnetic
resonance imagers), with the access of citizens from other OECD countries,
Canadians’ access was significantly poorer compared to three of the four.
Despite spending a full 1.6% of GDP more than the OECD average on health care,
Canadians were well down the league tables in access to CT scanners (21st of
28), lithotriptors (19th out of 22) and MRIs (19th out of 27). Moreover, access
to several of these technologies has worsened relative to access in other
countries over the last decade.